Certified Rhythm Analysis Technician (CRAT) Practice Exam

Question: 1 / 400

Which of the following is considered improper documentation in a patient's medical record?

The ECG was performed at 10:00 am and tolerated well by Mr. Smith.

Mr. Janes complained of chest pain during the ECG; Dr. Jackson was notified.

I did not perform the ECG because Mr. Harris is an old drunk and is nasty and dirty.

The statement indicating that "I did not perform the ECG because Mr. Harris is an old drunk and is nasty and dirty" represents improper documentation because it includes subjective, biased language rather than a factual, professional account of the patient's condition. Medical documentation should be objective, focusing solely on clinical facts, the patient's medical history, and relevant information pertaining to their care. Using derogatory terms and personal judgments about a patient's character or lifestyle not only compromises the professionalism required in medical records but also violates ethical standards and can have legal implications.

In contrast, the other statements provided focus on objective observations and clinical actions taken regarding the patient's health, which aligns with appropriate documentation practices. They present relevant medical information about the procedures performed or communicated without personal bias or judgment.

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The ECG was ordered due to Mr. Henderson's complaints of shortness of breath and chest pain.

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